In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.)

I authorize payment of medical benefits to Ahwatukee Psychological Services PLLC (Dr. Astrid Heathcote Psy. D) for any and all psychological services performed. I understand that I am financially responsible for the charges not covered by my insurance. Also in the event that an appointment is missed without 48 hours notice, I understand that my credit card will be automatically charged with the full fee of $200.